Fidelity versus flexibility: translating evidence-based research into practice.
BACKGROUND
Understanding the process by which research is translated into practice is limited. This study sought to examine how interventions change during implementation.


METHODS
Data were collected from July 2005 to September 2007. A real-time and cross-case comparison was conducted, examining ten interventions designed to improve health promotion in primary care practices in practice-based research networks. An iterative group process was used to analyze qualitative data (survey data, interviews, site visits, and project diary entries made by grantees approximately every 2 weeks) and to identify intervention adaptations reported during implementation.


RESULTS
All interventions required changes as they were integrated into practice. Modifications differed by project and by practice, and were often unanticipated. Three broad categories of changes were identified and include modifications undertaken to accommodate practices' and patients' circumstances as well as personnel costs. In addition, research teams played a crucial role in fostering intervention uptake through their use of personal influence and by providing motivation, retraining, and instrumental assistance to practices. These efforts by the research teams, although rarely considered an essential component of the intervention, were an active ingredient in successful implementation and translation.


CONCLUSIONS
Changes are common when interventions are implemented into practice settings. The translation of evidence into practice will be improved when research design and reporting standards are modified to help quality-improvement teams understand both these adaptations and the effort required to implement interventions in practice.
Cohen
Deborah J
DJ
Department of Family Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Somerset, New Jersey 08873, USA. cohendj@umdnj.edu
Crabtree
Benjamin F
BF
Etz
Rebecca S
RS
Balasubramanian
Bijal A
BA
Donahue
Katrina E
KE
Leviton
Laura C
LC
Clark
Elizabeth C
EC
Isaacson
Nicole F
NF
Stange
Kurt C
KC
Green
Lawrence W
LW
D003625:Data Collection; D019317:Evidence-Based Medicine / Q000379:methods*; D015438:Health Behavior; D006282:Health Personnel / Q000191:economics; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D009042:Motivation; D011314:Preventive Health Services / Q000379:methods*; D011320:Primary Health Care / Q000191:economics / Q000379:methods*; D012106:Research; D012107:Research Design; D014481:United States; D000078329:Workforce